Healthcare Provider Details

I. General information

NPI: 1770257073
Provider Name (Legal Business Name): ZACHERY HULET OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5349 W MAIN ST
KALAMAZOO MI
49009-1007
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-7627
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005530
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: